“The Nobodies”: unidentified dead bodies—a global health crisis requiring urgent attention
Authors: Halina Suwalowska, Joseph Ali, João Rangel de Almeida, Stephen Antonio Fonseca, Laura Jane Heathfield, Craig Adam Keyes, Robert Lukande, Lorna J Martin, Kate Megan Reid, Vina Vaswani, Harihar Wasti, Regis O Wilson, Michael Parker, Patricia Kingori
Journal: The Lancet Global Health (2023)

Every year, millions of dead people across the globe remain unidentified and are never returned to their families or communities.1Mazzarelli D Milotta L Franceschetti L et al.Twenty-five years of unidentified bodies: an account from Milano, Italy.Int J Legal Med. 2021; 135: 1983-1991Crossref Scopus (6) Google Scholar, 2Reid KM Martin LJ Heathfield LJ Understanding the burden of unidentified bodies: a systematic review.Int J Legal Med. 2023; 137: 1193-1202Crossref Scopus (0) Google Scholar The circumstances surrounding their death are often unknown, and their bodies go unclaimed. Identification represents one of the most basic of all human rights3Moon C Human rights, human remains: forensic humanitarianism and the human rights of the dead.Int Soc Sci J. 2016; 65: 49-63Crossref Scopus (41) Google Scholar and yet with continuing humanitarian disasters, infectious disease outbreaks, mass migrations on precarious and often deadly land and sea routes, as well as human trafficking, the numbers of unidentified dead bodies grow. The presence of unidentified bodies raises pressing ethical and practical concerns that demand immediate attention to successfully attain global health objectives including serving the vulnerable, reducing health inequalities, and responding to humaitarian crises. From an ethical standpoint, these individuals are often denied the respect they deserve, as they are buried without proper identification, often in mass graves, and without accompanying religious or cultural ceremonies.4The Economist(2022). At least 100,000 people are missing in Mexico. The Economist, June 30, 2022https://www.economist.com/the-americas/2022/06/30/at-least-100000-people-are-missing-in-mexicoDate accessed: May 1, 2023Google Scholar On a practical level, the shortage of resources results in the hasty disposal of these bodies without due regard.2Reid KM Martin LJ Heathfield LJ Understanding the burden of unidentified bodies: a systematic review.Int J Legal Med. 2023; 137: 1193-1202Crossref Scopus (0) Google Scholar Additionally, the scarcity of data on the number of unidentified dead bodies hampers the development of global health policies that could improve the health of marginalised and vulnerable populations. The treatment of unidentified dead bodies is a personal tragedy for the families of the deceased who face the anguish of so-called ambiguous loss. This psychological state, marked by uncertainty about the fate of the missing, has severe negative effects on an individual's wellbeing and health that makes identification of the dead a crucial global public health priority.5Cattaneo C Tidball Binz M Penados L Prieto J Finegan O Grandi M The forgotten tragedy of unidentified dead in the Mediterranean.Forensic Sci Int. 2015; 250: e1-e2Crossref PubMed Google Scholar Further, identification holds crucial legal implications, including obtaining death certificates necessary for claiming inheritance or transferring parental responsibilities. Lack of identification also hampers criminal investigations, as justice cannot be served if the victim is not named. Despite its importance, there is a lack of organised effort to identify the numbers of unidentified dead bodies globally and establish who they were in life. A few studies, such as a systematic review conducted by Reid and colleagues,2Reid KM Martin LJ Heathfield LJ Understanding the burden of unidentified bodies: a systematic review.Int J Legal Med. 2023; 137: 1193-1202Crossref Scopus (0) Google Scholar examined articles that have empirically explored the occurrences of unidentified bodies worldwide. The results of this review pointed out a surprisingly small number of articles (just 24 in total) providing data for 15 forensic facilities across only ten countries. The review found that unidentified bodies are more prevalent in low-income and middle-income countries (LMICs) due to socioeconomic challenges affecting identification systems. Climate change-related disasters exacerbate this issue, particularly in LMICs, where mass casualties and migration disproportionately increase. This data gap also extends to unidentified newborns,6du Toit C Martin LJ Heathfield LJ Investigation into abandoned neonates admitted to Salt River Forensic Pathology Mortuary, Cape Town.Forensic Sci Int. 2018; 292: 232-241Crossref Scopus (3) Google Scholar potentially undermining efforts to reduce child mortality and attain Sustainable Development Goals.7UNICEFGoal 3: ensure healthy lives and promote well-being for all at all ages.https://data.unicef.org/sdgs/goal-3-good-health-wellbeing/Date accessed: May 1, 2023Google Scholar Understanding who these individuals were requires a multi-step identification process, primarily relying on visual confirmation by next-of-kin and scientific methods such as fingerprints, DNA analysis, forensic anthropology, or dental features. However, the use of scientific identification methods often depends on antemortem records, which are typically inaccessible or non-existent, particularly in LMICs. A shortage of pathologists or other forensic specialists also makes identification particularly difficult. This challenge is further compounded by the perceived futility of investigating unidentified dead bodies by policymakers or stakeholders involved in the identification process.2Reid KM Martin LJ Heathfield LJ Understanding the burden of unidentified bodies: a systematic review.Int J Legal Med. 2023; 137: 1193-1202Crossref Scopus (0) Google Scholar Moreover, the burdened and underfunded forensic systems, scarce scientific resources, and inadequate infrastructure in many LMICs exacerbate the problem. Similar challenges are also encountered in determining the cause of death.8Suwalowska H Kingori P Parker M Navigating uncertainties of death: minimally invasive autopsy technology in global health.Glob Public Health. 2023; 182180065Crossref Scopus (0) Google Scholar The extremely high number of unidentified dead bodies, accompanied by minimal contextual data, has been referred to as a silent mass disaster.9Ritter N Missing persons and unidentified remains: the nation's silent mass disaster.Natl Inst Justice J. 2007; 256: 2-7Google Scholar When they were alive, many of these people have been marginalised due to social and health inequalities—for example, undocumented migrants, people who are members of disadvantaged minority ethnic groups, people of colour, the urban poor and homeless, individuals with severe mental illnesses, and other stigmatised health conditions.10Raghavendra Babu YP Joseph N Kadur K Mortality among homeless and unclaimed bodies in Mangalore city—an insight.J Forensic Leg Med. 2012; 19: 321-323Crossref PubMed Google Scholar The International Committee of the Red Cross and the Johannesburg Forensic Pathology Service highlight migrants as constituting a substantial proportion of unidentified bodies, as when they were alive they feared legal repercussions, experienced heightened vulnerability, and often succumbed to illness or violence.11Keyes CA Mahon TJ Gilbert A Human decedent identification unit: identifying the deceased at a South African medico-legal mortuary.Int J Legal Med. 2022; 136: 1889-1896Crossref Scopus (1) Google Scholar The International Organization for Migration's Missing Migrants Project—the singular initiative documenting migrant deaths on a global scale—reveals more than 50 000 migrant deaths since 2014, with approximately 60% remaining unidentified.12Black J Sigman Z 50,000 lives lost during migration: analysis of Missing Migrants Project data 2014–2022. Global Migration Data Analysis Centre, Berlin2022Google Scholar Despite its limitations, the project exposes the tip of the iceberg, as isolated migration routes and a lack of reporting skew figures. Some nations' non-disclosure of migrant death data intensifies the challenge, leaving the identities and profiles of most deceased migrants unknown. Current research networks attempting to address the crisis of unidentified bodies are in their infancy. Led by university academics, these voluntary efforts have limited scope and jurisdiction. Although the issue of unidentified bodies has garnered attention in specific contexts, such as the border between the US and Mexico13De León J Wells M The Land of open graves: living and dying on the migrant trail. University of California Press, Berkeley, CA2015Google Scholar and the crossing of the Mediterranean sea,5Cattaneo C Tidball Binz M Penados L Prieto J Finegan O Grandi M The forgotten tragedy of unidentified dead in the Mediterranean.Forensic Sci Int. 2015; 250: e1-e2Crossref PubMed Google Scholar there is a pressing need for more collaborative and interdisciplinary interventions to rectify the systemic inequalities that leave the causes of death for the world's most marginalised unknown and their bodies unidentified. The scarcity of data and the failure to recognise the identification of dead people as a pressing global health issue signify a blind spot and highlight an asymmetrical practice on the part of global health institutions and practitioners focusing on saving lives while often overlooking the significance of the dead.14Setel PW Macfarlane SB Szreter S et al.A scandal of invisibility: making everyone count by counting everyone.Lancet. 2007; 370: 1569-1577Summary Full Text Full Text PDF PubMed Scopus (333) Google Scholar This crucial scarcity of data has dire consequences, as it perpetuates a belief that those who are not counted, do not count.15Sallnow L Smith R Ahmedzai SH et al.Report of The Lancet Commission on the value of death: bringing death back into life.Lancet. 2022; 399: 837-884Summary Full Text Full Text PDF PubMed Scopus (129) Google Scholar A combined effort involving global and local actors is necessary, demanding the prioritisation of identification, especially for marginalised communities. Prioritising the identification of these individuals will not only improve statistical reporting but also pave the way for developing strategies to prevent avoidable deaths. This prioritisation is particularly crucial considering infectious disease outbreaks, migrant deaths, and climate-induced migrations that will inevitably leave a trail of unidentified dead bodies. Thus, initiatives such as WHO's efforts to strengthen the global architecture for health emergency preparedness, prevention, response, and resilience should incorporate the identification of unidentified dead bodies within surveillance and social protection systems.16WHOStrengthening health emergency prevention, preparedness, response, and resilience. World Health Organization, Geneva2023Google Scholar As for identification, the forensic medicine community has stressed the need for a standardised approach to identification at a global level.2Reid KM Martin LJ Heathfield LJ Understanding the burden of unidentified bodies: a systematic review.Int J Legal Med. 2023; 137: 1193-1202Crossref Scopus (0) Google Scholar This approach should make concessions for different levels of infrastructure and use all available methods of identification. It should also include the creation of databases that allow for cross-searching between records of unidentified bodies and those reporting missing people nationally, regionally, and internationally, with a public health mandate. Such efforts are crucial to allocate resources, build effective systems, and foster collaboration in addressing this humanitarian crisis. Recognising the dignity and personhood of unidentified dead bodies restores respect for those left behind, rectifies injustices, and acknowledges a long-neglected global problem. We declare no competing interests.